Colopharyngoplasty in Patients with Severe Pharyngoesophageal Corrosive Injury: A Complicated but Worthwhile Procedure to Restore GI Tract Continuity, A Case Series.

BACKGROUND
Pharyngoesophageal strictures (PES) after corrosive injury impose a problematic condition for both physicians and patients in terms of their management and patients' quality of life. Colopharyngoplasty is a complex procedure, which is used to restore swallowing in these severely disabled patients. We describe our experience in treating nine patients with severe PES after corrosive injuries in a referral center.


MATERIALS AND METHODS
A retrospective analysis of our database from 2009 to 2014 showed nine patients (seven men; age range: 18 to 47 years) with severe PES who underwent colopharyngoplasty ∼6 months (range: 4-10) after caustic material ingestion. All patients had a feeding jejunostomy tube before reconstruction. Esophagectomy with or without gastrectomy was performed in all patients, except for one; thereafter, an isoperistaltic segment of the left colon was pulled up, and a pharyngocolic anastomosis was performed. Eight patients had a tracheostomy created either before reconstruction due to respiratory symptoms or at the time of definitive surgery to prevent aspiration in the early post-operative period.


RESULTS
Almost all survivors had a satisfactory swallowing at the end of the follow-up (range: 4-60 months). The jejunostomy tube could be removed in all of the patients after a median of 5 months. One patient died of sepsis due to graft necrosis in the immediate post-operative period. Another patient died 5 months after the first surgery following a revision surgery for intractable dysphagia. At the end of the follow-up, only one patient tolerated tracheostomy tube decannulation. Two patients required laryngotracheal dissociation because of massive aspiration and recurrent episodes of pneumonia. Five patients still had a tracheostomy because of an severely destroyed larynx (two patients) and aspiration (three patients).


CONCLUSION
Colopharyngoplasty is considered a complicated but trustworthy procedure to restore gastrointestinal tract continuity after severe corrosive injury. Undeniably, laryngeal involvement adversely affects the functional outcome. The post-operative course is frequently protracted, accompanied with several problems. Aspiration is nearly the most problematic event in the early post-operative period, which mandates a multidisciplinary approach to manage it.


INTRODUCTION
Among benign causes of upper aero-digestive tract stenosis, caustic injuries are one of the most problematic situations to deal with. The management of pharyngolaryngeal involvement after ingestion of corrosive materials is challenging (1). Despite the presence of several therapeutic options, the gold standard has not been introduced yet, and each patient has to be approached individually. Awareness of some critical points (including the site and length of stenosis, status of the larynx and pharynx, and any previous procedure) is of great importance before proceeding to any kind of surgery.
Esophageal reconstruction at this level requires a great deal of experience; however, serious complications, unpredictable outcomes, and overall unsatisfactory functional results are common (2). Here, we describe our experience in managing patients with severe pharyngoesophageal strictures (PES) after corrosive injuries in an Iranian referral center, focusing on technical issues and functional outcomes.

MATERIALS AND METHODS
From January 2009 to January 2014, nine patients with severe PES after ingestion of caustic materials underwent colopharyngoplasty at our referral thoracic surgery ward.
Four of them underwent an emergent tracheostomy before admission due to respiratory distress. A protective tracheostomy was performed for the other patients at the time of surgery, except for one patient with an intact larynx.
All patients had a gastrostomy or jejunostomy tube for correction of malnutrition. Two of them underwent esophagectomy at other centers due to severe initial injuries.
The pre-operative evaluation consisted of a

Post-Operative Management:
We routinely started enteral nutrition via the jejunostomy tube on the 5 th post-operative day, except for cases with complications. Simultaneously, we initiated oral feeding if the patients were able to tolerate such. First, a semisolid diet was started to minimize aspiration, which is a common problematic event particularly in the early postoperative period. We expected higher risks of aspiration with fluids. According to our experience on tracheostomy tube as an effective tool to control aspiration, we did not attempt to decannulate such immediately. Thus, the tracheostomy tube was removed only if there was no evidence of aspiration. Two months following oral feeding toleration, the jejunostomy tube was then removed.

Follow-up:
Before and after the surgery, all patients were educated on how to control aspiration. In these educational sessions, our team trained the patients on special diets and different maneuvers in the post-operative period. After discharge, follow-ups were scheduled every 3 months and 6 months during the first and second years, respectively, and then annually. A good functional outcome was defined as the situation when the patients were able to eat or breathe without the need of any appliance and stoma. As shown in Figure    At the end of the follow-up period, all survivors (six patients) had a satisfactory swallowing. The jejunostomy tubes were removed ~2 months after oral feeding toleration.

DISCUSSION
The actual incidence of caustic injuries in the upper aero-digestive tract is underestimated in developing countries owing to cultural, social, and economic factors (4). The management of patients with caustic injury is generally a demanding issue, particularly in adults with suicidal attempts as the most common cause of injury (5).
Consequently, these patients are not as cooperative as others. Psychiatric stability is an important prerequisite before any reconstruction in these patients.
The incidence of pharyngeal and upper respiratory tract involvements following caustic ingestion has been rarely reported (6); decision-making for these injuries is findings (14). Hence, the decision to perform an emergent surgery for corrosive injuries has to be made judiciously, mostly on the basis of clinical findings rather than radiologic or endoscopic findings alone.
In general, strictures following corrosive injuries tend to be long, narrow, rigid, and multiple (10). Thus, it is comprehensible that dilatations, as an initial therapeutic option (15), accompany a high failure rate. In short segment stenoses, a free jejunal graft or forearm flap could be appropriate for reconstruction (16,17).